Electrolyte Replacement Guidelines (Adults)
Canberra Health ServicesGuideline Electrolyte Replacement Guidelines (Adults) Contents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc52974263 \h 1Guideline Statement PAGEREF _Toc52974264 \h 2Scope PAGEREF _Toc52974265 \h 2Section 1 – Potassium PAGEREF _Toc52974266 \h 3Section 2 – Phosphate PAGEREF _Toc52974267 \h 6Section 3 – Magnesium PAGEREF _Toc52974268 \h 7Section 4 – Calcium PAGEREF _Toc52974269 \h 8Evaluation PAGEREF _Toc52974270 \h 9Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc52974271 \h 9References PAGEREF _Toc52974272 \h 10Definition of Terms PAGEREF _Toc52974273 \h 11Search Terms PAGEREF _Toc52974274 \h 11Guideline StatementBackgroundThis document has been developed to describe and guide the best practice for electrolyte replacement in adult patients across Canberra Health Services (CHS).Key ObjectiveThis document aims to:Provide guidance to clinicians on the safe and appropriate use of oral and intravenous electrolyte replacement for potassium, phosphate, magnesium and calciumDescribe the products that are available across CHS and how to safely prescribe and administer themDocument the expected standard for intravenous electrolyte prescribing and administration in the context of replacement therapy.Alerts Concentrated electrolytes, in particular potassium, are high risk medications, which means if an error is made in dispensing, preparation or administration it is more likely to lead to patient harm. To prevent causing avoidable harm to patients, extra care must be taken when prescribing and administering electrolytes, particularly via the intravenous route. All staff should follow the standards for storage and use of intravenous potassium described in the Medication Handling Policy.Back to Table of ContentsScopeThe Clinical Guideline “Electrolyte Replacement in Guidelines (Adults)” applies to nursing, pharmacy and medical staff caring for adult patients of the Canberra Health Service. The following are out of scope:Administration of electrolytes to patients in the Intensive Care Unit or Resuscitation Bay of the Emergency Department Administration of electrolytes in emergency conditions such as asthma and cardiac arrhythmiaManagement of sodium abnormalities is complex and is out of scope for this guidelineElectrolyte replacement for paediatric patientsPatients with complex alterations in electrolyte balance, acid base status, renal function or disturbance of other components of plasma. Back to Table of ContentsSection 1 – Potassium1.1 High-risk Medication1The administration of intravenous (IV) potassium is a potentially dangerous procedure:Errors in calculation or admixture of concentrated potassium containing solutions can result in serious adverse reactions and even death.IV bolus administration of concentrated potassium can be lethal.When high concentrations are used, even minor divergence from the recommended rate of administration can be cardiotoxic.The expected standard of practice is to prescribe pre-mixed potassium containing infusion bags. There are pre-mixed bags available to suit almost all clinical situations and it is MANDATORY for these to be considered as the first option.Preparation of a boutique potassium containing solution for intravenous infusion is a high-risk process and not recommended due to the following risks:Errors in calculation of potassium additive, leading to confusion regarding the final concentration.Inadequate mixing of potassium and infusion, leading to pooling of the potassium additive and inadvertent potassium bolus.Additional potassium chloride MUST NEVER be added to a pre-mix potassium bag and MUST NEVER be added to hanging or running IV bags.Prescribe electrolytes by writing the FULL NAME (and salt). Chemical abbreviations are not acceptable e.g. potassium chloride (NOT KCl).The standards for storage and use of intravenous potassium is described in the Medication Handling Policy.Potassium Replacement Recommendations1-8, 13 Check magnesium levels – repletion of magnesium stores will facilitate more rapid correction of hypokalaemia.Serum Potassium RoutePotassium DosageMonitoring RequiredMild Deficit: Serum Potassium: 3.1 – 3.5 mmol/L OralPotassium chloride slow release tablets: 2 tablets (16 mmol K+) BD or TDSORPotassium chloride effervescent tablets: 1-2 tablet (14-28 mmol K+) BD or TDSDaily serum potassium ECG not requiredModerate Deficit: Serum Potassium: 2.5 – 3.0 mmol/L Oral(preferred)AND/ ORIVPotassium chloride slow release tablets 3 tablets (24 mmol K+) TDS ORPotassium chloride effervescent tablets 2-3 tablets (28-42 mmol K+) TDSAND/ORIV Peripheral Line (rate not to exceed 10mmol/hr)30 mmol potassium chloride in 1000mL pre-mixed bag OR10 mmol potassium chloride in 0.29% sodium chloride (isotonic) pre-mixed bag (100mL)Serum potassium at least every 6-12 hoursECG is required if symptomatic (arrhythmia, marked muscle weakness or rhabdomyolysis)Severe Deficit:Serum Potassium: Less than 2.5 mmol/L OralANDIVPotassium chloride slow release tablets: 3 tablets (24 mmol K+) TDSAND/ ORPotassium chloride effervescent tablets 2 tablets (28 mmol K+) TDSANDIV Peripheral Line (rate not to exceed 10mmol/hr)10 mmol potassium chloride in 0.29% sodium chloride (isotonic) pre-mixed bag (100mL)ORIV Central Line (rate not to exceed 20mmol/hr without continuous ECG monitoring)10 mmol potassium chloride in 0.29% sodium chloride (isotonic) pre-mixed bag (100mL)Serum potassium every 4-6 hoursECG requiredNote: Information on the use of potassium acetate is not included in this guideline. This should only be used for potassium replacement in critical care areas.1.3 Available Oral Potassium Supplements in CHSGradual replacement of potassium (via oral route) is preferred, if clinically appropriate since the relatively slow absorption from the gastrointestinal tract prevents sudden large increases in plasma potassium concentrations. If a patient is fluid restricted, ALWAYS consider giving potassium via the oral route.Potassium ChlorideProductPotassium contentBrand NamesSlow release tablet8 mmol (600 mg)Span K?Effervescent tablets14 mmolChlorvescent? (Dissolve in 100-150mL water)Oral mixture 20 mmol (1.5g) in 15mLPotassium chloride Oral Mixture 10% w/v? (Note: Reserved for paediatric patients unable to tolerate Chlorvescent? preparation)Note: Potassium citrate products are also available but are indicated for the prevention of kidney stones and increasing urine pH.1.4 Available Pre-mixed Potassium Bags for Intravenous InfusionThe pre-mixed potassium bags for intravenous infusion available at CHS are detailed in the table below. Potassium (mmol)FluidVolumeOrder From100.29% sodium chloride (isotonic)100 mL*Pharmacy200.45% sodium chloride and 5% glucose1000 mL300.18% sodium chloride and 4% glucose1000 mLSupply Services, Mitchell5% glucose1000 mLHartmann’s solution1000 mL0.9% sodium chloride1000 mL100.45% sodium chloride and 2.5% glucose500 mL*The isotonic formulations contain a different concentration of sodium chloride to the other pre-mixed bags. This enables safe peripheral administration. The same concentration cannot be made with normal saline (sodium chloride 0.9%) bags.Note: Information on using potassium dihydrogen phosphate should be reserved for phosphate replacement and can be found in the Phosphate section of this document. 0.9% sodium chloride is the preferred infusion fluid as 5% glucose may cause trans-cellular shift of potassium into cells5.Monitor the injection site closely due to the risk of phlebitis5. Supply of potassium chloride 10 mmol/10 mL ampoules as imprest is restricted to the Intensive Care Unit, Operating Theatres, the Resuscitation Bay in the Emergency Department, and Paediatric High Care and this stock is not to be provided to other patient care areas. All staff must refer to the standards for storage and supply of intravenous potassium stated in the Medication Handling Policy. Back to Table of Contents Section 2 – Phosphate2.1 Phosphate replacement recommendations2-6, 9, 13There are no national guidelines for the treatment of acute hypophosphataemia and practice varies widely across Australian hospitals. The use of phosphate for other indications such as re-feeding syndrome or use in the critical care setting is out of scope and, specialist advice should be sought. Concomitant hypocalcaemia should also be corrected before treating hypophosphataemia to prevent further hypocalcaemia.Serum PhosphateRoutePhosphate DosageMonitoring RequiredMild Deficit:Serum Phosphate: 0.5 - 0.75 mmol/LTreatment not usually required as can be treated by increasing dietary intake of food high in phosphate (e.g. dairy products), except if alcoholism/ withdrawal, malnutrition, re-feeding syndrome, receiving TPN, renal phosphate wasting, recovery from DKA or respiratory failure. Moderate Deficit: Serum Phosphate: 0.3 - 0.49 mmol/L Oral OR IV (if symptomatic)Effervescent phosphate tablet 500mg* (Phosphate Sandoz?): 1- 2 tablets (16.1 – 32.2 mmol phosphate) up to TDS ORIV Peripheral Line (Administer over 2-6 hours)10 mmol potassium dihydrogen phosphate (KH2PO4) in 0.9% sodium chloride pre-mixed bag (250mL)OR10 mmol sodium dihydrogen phosphate (NaH2PO4) in 250mL 0.9% sodium chloride *Dose may be limited by diarrhoeaDaily Serum phosphate & calcium Severe Deficit: Serum Phosphate: Less than 0.3 mmol/L IVIV Peripheral Line (Administer over 2 hours)10 mmol potassium dihydrogen phosphate (KH2PO4) in 0.9% sodium chloride pre-mixed bag (250mL)OR10 mmol sodium dihydrogen phosphate (NaH2PO4) in 250mL 0.9% sodium chloride Serum phosphate & calcium every 6-12 hoursAvailable Oral replacementPhosphate ProductPhosphate contentBrand NamesEffervescent tablets*16.1 mmol (500mg)Phosphate Sandoz?* Tablet should be dissolved in approximately 75mL of water and taken orally. Available Intravenous replacement FormElectrolyte ContentAvailabilityPotassium dihydrogen phosphate (KH2PO4)10 mmol potassium and 10 mmol phosphate in 0.9% sodium chloride pre-mixed bag (250 mL)Pre-mixed bag available from Pharmacy and afterhours CNCSodium dihydrogen phosphate (NaH2PO4)10mmol sodium and10mmol phosphate in 10mL vialVial available in Pharmacy and afterhours CNC. Back to Table of Contents Section 3 – Magnesium3.1 Magnesium replacement recommendations2-6, 10, 11, 13Serum MagnesiumRouteMagnesium DosageMonitoring RequiredMild to Moderate Deficit: Serum Magnesium: 0.4 – 0.7 mmol/L OralMagnesium aspartate (500 mg)*1 to 2 tablets (1.54 – 3.08 mmol) BD. Up to 6 tablets (9.24mmol) daily in divided doses may be required. *Dose may be limited by diarrhoeaDaily or second daily serum magnesiumSevere Deficit: Serum Magnesium: Less than 0.4 mmol/L ORSymptomatic (e.g. tremor, weakness, cardiac arrhythmias, convulsions)IVIV Peripheral Line 10 to 20 mmol magnesium sulphate (MgSO4) in 100mL 0.9% sodium chloride over 1 hour*. Repeat if necessary, at 4 hourly intervals according to response. *Maximum infusion rate 36 mmol/hour.Serum magnesium levels or clinical symptoms within 6 to 12 hours. Note: Hypomagnesemia may cause concomitant refractory hypokalaemia and hypocalcaemia, ongoing monitoring and replacement of all electrolytes is required3.3 Available Oral replacementFormApproved NameMagnesium contentCHS RestrictionTabletMagnesium aspartate*500mg (1.54mmol per tablet)n/aOral solutionMagnesium Chloride 1mmol/mL (100mL) Restricted for paediatric patients with narrow bore NG/PEG tubes. *Poor oral absorption 3.4 Available Intravenous replacement in CHS5FormElectrolyte ContentAvailabilityMagnesium sulphate (MgSO4) 2.5 g/ 5mL concentrated ampoule10 mmol magnesium sulphate in 5 mLVial available in Pharmacy and afterhours CNC. Magnesium sulphate (MgSO4) 5 g/ 10mL concentrated ampoule20 mmol magnesium sulphate in 10 mLBack to Table of Contents Section 4 – Calcium4.1 Calcium replacement recommendations2-6, 12, 13Remember plasma calcium (even corrected for albumin) is an unreliable measure of functional (ionised) calcium. If resistant to treatment, exclude hypomagnesaemia. Serum CalciumRouteCalcium DosageMonitoring RequiredMild Deficit:Serum corrected calcium: 1.90 - 2.10mmol/L OralCalcium carbonate 1500mg (elemental calcium 600mg) 1-2 tablets (15-30mmol) daily.Serum calcium second dailyModerate Deficit: Serum corrected calcium:1.5 - 1.89 mmol/L OralCalcium carbonate 1500mg (elemental calcium 600mg) 2-3 tablets (30-45mmol) BD-TDS. Serum calcium dailySevere Deficit: Serum corrected calcium: Less than 1.5 mmol/L or 0.75mmol/L ionised ORSymptomatic hypocalcaemia (e.g. perioral/ finger paraesthesia, seizures, tetany, positive Chvostek’s/ Trousseau’s) IVIV Peripheral Line/ central line Calcium Gluconate 10% (10 mL vial)1 to 2 vials (2.2 to 4.4 mmol) in 100 mL 0.9% sodium chloride over 20 to 30 minutesTHENCalcium Gluconate 10% (10mL vial) 10 vials (22 mmol) in 900 mL 0.9% sodium chloride at 50 mL/hourSerum calcium at least every 4 hours Available Oral replacement Calcium ProductCalcium contentBrand NamesCalcium Carbonate tablet 1500mg (elemental calcium 600 mg) Caltrate?, Calci-Tab 600?, Cal-600?Available Intravenous replacement FormElectrolyte ContentAvailabilityCalcium Gluconate10% (2.2 mmol/10 mL)Vial available in Pharmacy and afterhours CNC.Note: Calcium gluconate is preferred to calcium chloride as it is less toxic to peripheral veins. Extravasation of calcium can cause localised skin necrosis. Back to Table of Contents Evaluation OutcomeSafer prescribing and administration, and standardised process for prescribing potassium, phosphate, magnesium and calciumMeasuresMonitoring and review of incidents associated with electrolyte replacement for potassium, phosphate, magnesium and calcium.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesCHS Consent and TreatmentCHS Medication Handling Policy CHS High Risk Medicines PolicyCHS Patient Identification and Procedure Matching PolicyProceduresCHS Pathology requests and specimens ProcedureCHS Patient Identification and Procedure Matching ProcedureLegislationMedicines, Poisons and Therapeutic Goods Act 2008Medicines, Poisons and Therapeutic Goods Regulation 2008Therapeutic Goods Act 1989Therapeutic Goods Regulation 1990Back to Table of ContentsReferencesHigh Risk Medication Alert – Intravenous Potassium Chloride, Australian Commission on Quality and Safety in Healthcare. October 2003.Electrolyte Abnormalities. Australian Therapeutic Guidelines. Published March 2014. Amended June 2019 ? Therapeutic Guidelines Ltd (eTG November 2020 edition).MIMS Online. Full Product Information (online). Available at: Medicines Handbook 2020 (online). Available at: Injectable Drugs Handbook 8th edn (online). Available at: 2020 (online) Available at: A. How should intravenous potassium chloride be administered in adults. Medicines Q&A 186.2. Welsh Medicines Information Centre. Cardiff July 2008.Mount, D., 2020. Clinical Manifestations And Treatment Of Hypokalemia In Adults. Uptodate. Available at: , A. and Stubbs, J., 2020. Hypophosphatemia: Evaluation And Treatment. Uptodate. Available at: < Joyce Wu and Andrew Carter. Magnesium: the forgotten electrolyte, Australian Prescriber: 2007;30:102-5.Yu, A., 2020. Hypomagnesemia: Evaluation And Treatment. Uptodate. Available at: Goltzman, D., 2020. Treatment Of Hypocalcemia. Uptodate. Available at: Health Medicines Regulation and Quality, Fluid and Electrolyte Guideline Working Party, 2016. Prescribing HYPO-Electrolyte Disturbances In Adults. The State of Queensland, p.1.Back to Table of ContentsDefinition of Terms K+ = PotassiumKCl = Potassium chloridePO4- = PhosphateKH2PO4 = Potassium dihydrogen phosphateNaH2PO4 = Sodium dihydrogen phosphateMg2+ = MagnesiumMgSO4 = Magnesium sulphate Ca2+ = CalciumHypokalaemia = Low potassiumHypophosphataemia = Low phosphateHypomagnesaemia = Low magnesiumHypocalcaemia = Low calciumBack to Table of ContentsSearch Terms Potassium, Hypokalaemia, Phosphate, Hypophosphataemia, Magnesium, Hypomagnesaemia, Calcium, Hypocalcaemia, ElectrolyteBack to Table of ContentsDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 16/09/2020Complete ReviewAshwin Swaminathan, ED Medical Services GroupCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS12:028Potassium Replacement Prescribing and Monitoring - Adult ................
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